Uveitis Flashcards
Anterior Uveitis (Iritis/Iridocyclitis)
Symptoms: Pain, redness, photophobia, consensual photophobia (pain in other eye), tearing, decreased vision.
Signs: Cells and flare, ciliary flush (redness around limbus), KPs. Possible Band Keratopathy. Associated with HLA-B27, JIA.
Etiology: Idiopathic, HLA-B27 (Ulcerative Colitis, Reactive Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis), post-op inflammation
Testing: Order testing if bilarteral, granulomatous or recurrent, minimal testing of Syphillis, sarcoidosis and TB (in at risk patients), so RPR or VDRL, FTA-ABS for Syphillis. PPD and/or IGRA, chest CT and ACE for Sarcoidosis. Other may include HLA-B27, ANA and RF testing for unilateral or bilateral alternating.
Treatment: Cycloplegic for pain and avoiding synechia formation, Steroid Q1-6Hrs (consider loading dose of 5 drops in 5 minutes)
Follow Up: 1-7 days. Check AC and IOP. Check for CME.
Toxoplasmosis:
Symptoms: Blurred vision, floaters, possible photophobia and pain
Signs: Unilateral white retinal lesion that may be adjacent to a previous Toxo chorioretinal scar. Vitreous inflammation directly over the lesion. Increased IOP in 10-20%
Etiology: Cat, undercooked meat
Treatment: If peripheral lesions, just treat the uveitis or IOP. If central to macula, Pyrimethamine (Spiramycin if pregnant or breast feeding). Reduce IOP if necessary
Follow Up: 3-7 days
Ocular Sarcoidosis: Most common in 20-50 y.o. and black.
Symptoms: Uni/bilateral pain, photophobia and decreased vision.
Signs: Iris nodules, Mutton Fat KPs, sheathing along peripheral retinal veins (candlewax drippings). Can have posterior synechiae.
Sarcoidosis in a granulomatous inflammation of the body. Will show in lungs, hence chest CT or PPD.
Treatment: Refer to internist or pulmonologist. Treat anterior or posterioir uveitis as normal. Refer to OMD for posterior uveitis.
Follow Up: 1-7 days to check AC, IOP. Monitor every 2-6 weeks for steroid response.
Behcets Disease:
Symptoms: Sudden onset bilateral decrease in vision, floaters, photophobia, mild/moderate pain possible.
Signs: Painful oral ulcers and at least 2 of the following: genital ulcers, skin lesions, positive behcetine test, eye lesions. Ocular signs: Bilateral hypopyon, AC reaction, scleritis occasionally. Vitritis, retinal vasculitis, arterial attenuation, retinal neo, waxy optic nerve pallor, RD.
Epidemiology: 20-40 y.o. Japanese, Turkish, or Middle Eastern.
Treatment: Blindness may occur in 3-4 years if untreated. Death from CNS involment may occur. Proper referral for immunosuppressive therapy is critical. Topical steroids Q1-6H and cycloplegics for anterior inflammation. Systemic steroids (prednisone po daily or IV methylprednisolone for 3 days). ANy patient with Behcets and posterior uveitis needs to be referred to a specialist for initiation of immunosuppressive therapy.
Follow Up: Daily during inflammation to check progress and IOP. Refer to uveitis specialist.
Cytomegalovirus Retinitis
Symptoms: Scotoma or decreased vision uni/bilaterally. Floaters, photopsias. Pain and photophobia is uncommon. Often asymptomatic.
Signs: CD4+ of <100 cells/mm3, confluent areas of necrosis with prominent hemes starting along the major retinal arcades. May be associated with anterior uveitis and non-granulomatous KPs, vitritis, RPE atrophy, RRD (1/3 cases, esp when 25% of retina is involved).
Etiology: AIDS and immunocompromised.
Treatment: Refer to OMD and internist or infectious disease specialist. Valganciclovir 900mg po BID x 21 days, then 900mg po QD. Alternatively IV Ganciclovir, Foscarnet or Cidofovir.
Follow Up: AIDS patients with CD4+ of <100 cells/mm3 should be seen every 3-6 months since this disease is generally asymptomatic.
Acquired Syphilis:
Symptoms:
Signs: Patchy hyperemia of the iris with fleshy, pink nodules near the iris sphincter, acute placoid macular chorioretinitis, punctate inner retinitis. Rarely a dilated iris vessel called an iris roseolae. Any sort of ocular inflammation can be traced back to syphilis.
Etiology: STD
Treatment: Penicillin IM or IV. Treat concurrent Anterior uveitis as normal. Concurrent treatment of Chlamydia with single dose Azithromycin 1 g po is indicated. Refer to infectious disease specialist, mandatory in neurosyphilis.
Congenital Syphilis:
Symptoms:
Signs: (Patchy hyperemia of the iris with fleshy, pink nodules near the iris sphincter, acute placoid macular chorioretinitis, punctate inner retinitis. Rarely a dilated iris vessel called an iris roseolae. Any sort of ocular inflammation can be traced back to syphilis.) Hutchinson’s sign (Wide spaced front teeth, deafness, Interstitial keratitis), secondary cataracts, salt-and-pepper fundus, iridocyclitis.
Treatment: Same as acquired syphilis - Penicillin IM or IV, however dosing should be handled by pediatrician or infectious disease specialist
Post-Op Acute Endophthalmitis:
Symptoms: Sudden onset pain, decreased vision day(s) after surgery.
Signs: Hypopyon, AC reaction, vitreous cells and haze, decreased red reflex. Can also have eyelid and corneal edema, and conjunctival injection and chemosis.
Etiology: Most likely Staph Epidermidis, followed by Staph Aureus and Strept species. Least common is G(-) bacteria. Bleb associated is generally Strept or G(-).
Post-Vitrectomy is generally Staph Epidermidis
Treatment: Send to surgeon. Prevention with Povidone-Iodine solution prior to surgery is most important.
Other Treatment: Vitreous or AC tap followed by intravitreal injection of vancomycin or ceftrazidime and possible IV dexamethasone. Consider topical Predforte and vancomycin or tobramycin Q1h around the clock for 1-2 days. Also consider pars plana vitrectomy is light perception.
Follow Up: Every 12-24 hours initally
Post-Op Subacute (weeks -> months s/p) Endophthalmitis:
Symptoms and signs similar to acute Endophthalmitis.
Treatment similar to acute Endophthalmitis without steroids initially.
Same follow up as Endophthalmitis
Sympathetic Ophthalmia:
Symptoms: Bilateral eye pain, redness, photophobia, decreased vision (near, then distance). History of trauma or surgery to an eye, generally (90%) within 1 year of symptoms.
Signs: Any inflammation of the uninvolved eye. Bilateral Mutton Fat KPs, iris nodules, PAS, iris neo, cataract, papillitis. Earliest signs may be loss of accommodation or a mild anterior or posterior uveitis in the uninjured eye.
Treatment: Prevent spread by enucleating a blind, traumatized eye before a reaction can occur (generally within 14 days of trauma). Once the reaction occurs, enucleation has no benefit.
Topical steroids Q1-2H or periocular or intravitreal steroids.
Follow Up: Every 1-7 days initially to monitor therapy and IOP. Maintain steroid for 3-6 months with 3-4 week check ups.
The long term prognosis with treatment is good with 75% of eyes seeing >20/40 at 1 year follow up.
